In healthcare, Clinical Decision Support (CDS) systems are used for processing radiology information and as an aid to create accurate and complete reporting.
In radiology (and in many other medical disciplines), reports are produced to document what was found, including an impressions and recommendations section. Such reports may serve several functions: communication to the referring physician, billing, documentation for own use. When a patient returns for a follow-up examination, the report may have to be read again. Also, for management reporting or medical research, there is a desire to do statistics over cases. This is a different use of the same report.
Radiology reporting may be performed using dictation. The dictated words may be transcribed manually and/or using automatic speech recognition. The report that is created has an unstructured text, optionally with a number of sections and paragraphs. Systems that produce a report with machine readable structure are also known. The paper “Automated Structured Reporting of Imaging Findings Using the AIM Standard and XML”, by S. L. Zimmerman et al., in RadioGraphics 2011; 31:881-887, published online doi:10.1148/rg.313105195, discloses a system that provides a mouse-keyboard interface to allow a radiologist to enter details into a report. The advantage of a structured representation is that different renderings of the report can be produced for different recipients: e.g. an oncologist (interested in disease progression) may get a different report than a surgeon (interested in surgical options), which is again different from the reports for a general practitioner or a patient.
Sometimes the report is drafted based on a template. This still results in unstructured text, although the format, content and terminology has been standardized to an extent.
An important purpose of radiology is to answer the clinical question asked by a referring physician by means of a radiology request. In today's radiology workflow, images may be read and reports may be prepared, dictated, revised, and approved by different people. Furthermore, reporting efforts include preparing the presentation or conferencing of the patient case, because communicating radiological findings is as important as the rendering of interpretation.